INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on June 30 and July 1 and 2, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on August 4, 2008.
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Plan of Correction
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715.16(c)(1)(i-iv) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(1) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to three times weekly and receive no more than a 2-day take-home supply of medication when, in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 months.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
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Observations
Based on a review of 16 patient records, five were required to document the basis for take-home privileges. The facility failed to document reasons to permit tri-weekly take home privileges for patient # 11.
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Plan of Correction
Program Director informed all staff of the need to adequately document rationale for granting client take-home privileges. Take-home privilege criteria was reviewed with staff on 7/22/08.
Program Director will also inform Medical Director by 7/28/08 of the need to adequately document rationale for granting client take-home privileges.
The Program Director will monitor for compliance by reviewing 5 random charts per month and 1 chart per week will be monitored by a nurse in the peer review process.
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717.18(a)(2) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(2) Employment services.
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Observations
Based on a review of policy and procedure, facility records and an interview with staff, the facility failed to maintain a current referral agreement for employment services.
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Plan of Correction
The referral agreement between Pyramid Healthcare Dolminis and the office of Occupational Vocational Rehabilitation Services has been renewed. Effective immediately. Director has implemented system to alert necessary staff of upcoming expiration dates for all referral agreements 1 month prior to expiration. |
715.18(a)(3) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(3) Adult educational services.
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Observations
Based on a review of policy and procedure and a staff interview, the facility failed to maintain a current referral agreement for educational services.
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Plan of Correction
The referral agreement between Pyramid Healthcare Dolminis and the office of Occupational Vocational Rehabilitation Services has been renewed. Effective immediately. Director has implemented system to alert necessary staff of upcoming expiration dates for all referral agreements 1 month prior to expiration. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of 16 patient records, the provision of psychotherapy counseling services was reviewed in ten records. The facility failed to provide each patient with the minimum requirement of an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in 2 of 10 records # 1 and 9. Patient # 1 received 1.25 hours of psychotherapy in April 2008, 1.0 hour in May 2008, and 1.25 hours in June 2008; an average of 1.20 hours per month. Patient # 9 received 1 hour of psychotherapy in April 2008, 2.25 hours in May 2008, and 2.25 hours in June 2008; an average of 1.8 hours per month.
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Plan of Correction
Absolute holds are been being place on clients who are scheduled for individual and/or group sessions and they are not permitted to dose until after they attend their scheduled function. Client attendance has risen from 44.85% to 97.19% in the last 4 months.
Clients are now being referred to specific groups relevant to their needs as addressed on their treatment plans in an effort to increase client engagement in the treatment process.
The Program Director will monitor for compliance by reviewing Client Hours Monitoring Grid monthly.
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715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
Based on a review of 20 patient records, four were required to have discharge summaries. The facility failed to follow a policy and procedure that included issuance of written documentation to a patient prior to the commencement of their involuntary discharge in 1 of 4 records reviewed. Patient # 6 was given a 7 day involuntarily detox effective 2/22/08 and subsequently discharged on 2/29/08; documentation in the patient record revealed the letter of termination was mailed to him on the date of his discharge (2/29/08).
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Plan of Correction
Program Director reiterated to staff that if a client is going to be involuntary discharged they will be given an involuntary discharge notification explaining why they are being discharged from the program and how they may appeal this decision the day they are informed of the discharge.
All Discharges will be approved by the Medical Director and Program Director. Program Director will monitor for compliance prior to approving discharge.
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715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on review of 16 patient records, four were required to have discharge summaries. The facility failed to ensure all efforts had been initiated to retain the patient prior to the involuntary termination. Patient # 6, was admitted on October 27, 2007 and involuntarily terminated on February 29, 2008 for financial reasons. Although financial responsibility was placed on the treatment plan less than a month prior to the termination, the plan lacked measurable goals and actions steps specific to the patient's needs. The brevity of this timeframe failed to allow the patient time to implement the treatment plan.
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Plan of Correction
A new protocol was implemented prior to the monitoring visit that requires the Utilization Review Coordinator and Counselor to meet with any client who is having difficulty paying for services or who's funding has been discontinued in an attempt to obtain other means of funding and/or to implement a payment plan based on client's financial ability to pay for services at that time.
The UR Coordinator contacts funding sources and advocates on client's behalf. Counselors are required to implement a financial responsibility treatment plan based on the outcome of the session between the UR Coordinator, the Counselor and the client.
The treatment plan is specific to what is expected of the client, financial responsibility, timeframes, reporting of changes, etc. The financial session and the implementation of the treatment plan are being conducted/implemented as soon as the UR Coordinator and/or the Counselor is made aware of the problem funding/financial issue.
The UR Coordinator's documentation is now being placed in the client's chart.
All clients' are being given substantial time and opportunity to implement treatment plans as well as, support with funding issues.
The Program Director and UR Coordinator will monitor for compliance of funding issues. All Discharges will be approved by the Medical Director and Program Director.
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715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on a review of 16 patient records and the facility's policy and procedures, the facility failed to include an appeal process in their grievance policy. Patient #6 had an involuntary detoxification initiated without notice of his right to appeal.
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Plan of Correction
The following has been edited in the policy and procedure regarding involuntary terminations.
If a client is going to be involuntary discharged they will be given an involuntary discharge notification. This notification will explain why they are being discharged. It will also explain how the patient may appeal this decision. They must complete an appeal form explaining why the discharge should be reconsidered. This form must be completed and returned to the Program Director within 48 hours of their notification. A medically supervised withdrawal will not begin until after this 48 hour period. Any appeals received after the 48 hour period will be considered on an individual basis. The client will receive a decision of their appeal within 48 hours after it has been turned in.
Program Director has reminded staff of the importance of this process and the need for this protocol to be followed.
All Discharges must be approved by the Medical Director and Program Director. Program Director will monitor for compliance prior to approving discharge.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of 16 patient records, 3 were required to have annual physical examinations by the physician. The facility failed to document that patient # 9 received his annual physical in a timely manner; the physical reexamination was due in May, 2008 but had yet to be completed at the time of this site visit, July 2, 2008.
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Plan of Correction
The annual evaluation was missed during a change in the annual evaluation monitoring protocol system. This new protocol system for monitoring the annual evaluation due date was implemented and has proven to be a productive monitoring system since implementation.
The Program Director will monitor for compliance by reviewing 5 random charts per month and 1 chart per week is monitored by each nurse in the peer review process.
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715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
A review of 16 patients records, 8 were reviewed for progress note content, revealed a pattern of a failure to address the issues on the treatment plan. Instead, they recorded therapy group involvement the patients attended that was based on time and availability rather than clinical need. Patient records # 11, 13 and 14 contained progress notes that did not reference issues that were identified in their treatment plans.
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Plan of Correction
Program Director met with staff and informed them of the lack of information being documented in the progress notes and the need to increase their documentation of the information discussed in individual therapy sessions pertaining to areas identified on the client's treatment plans.
Program Director and Inpatient Clinical Supervisor are scheduled to conduct a training on 7/29/08. A component of this training will address clinical documentation and progress note documentation content its and relevance to treatment plans. All staff will be instructed of the need to address treatment plan goals and objectives in the progress notes as well as other relevant information.
The goal of this training is to ensure that the notes and treatment plans flow together nicely.
The Program Director will monitor for compliance by reviewing 5 random charts per month and 1 chart per week is monitored by each clinician in the peer review process.
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715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
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Observations
Based on a review of 16 patient records, 9 were reviewed for the content of the record of service. The facility failed to ensure the patients' record of services was complete and in chronological order in 3 of 9 patient records reviewed, specifically, # 3, 11 and 12.
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Plan of Correction
During clinical staffing meeting on 7/9/08, Director informed staff of the importance of not waiting to record client meetings in the record of service and the need to maintain the Record of Service in chronological order.
The Program Director will monitor for compliance by reviewing 5 random charts per month and 1 chart per week is monitored by each clinician in the peer review process. Director will follow program's policy and procedure if substandard performance continues.
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715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of 16 patient records, 4 were required to have discharge summaries. The facility failed to provide detailed summaries for patient discharges in patient records # 5, 6, and 8; specifically the discharge summaries failed to include the reason for the patient seeking treatment, the patient's response to treatment and status on discharge.
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Plan of Correction
A new discharge summary is currently in the process of being implemented and a training for its use is scheduled for 7/15/08. This summary includes the initial assessment which will indicate the reason the client entered treatment as well as other demographic information. The initial diagnosis will be indicated. The clients progress in treatment will be documented to include their level of participation, progress on treatment plans, family involvement, referrals, etc. A final assessment will document the clients status at discharge to include prognosis and type of discharge. The discharge diagnosis and any aftercare plans and/or referrals will be noted. The Program Director will monitor for compliance by reviewing 5 random charts per month and 1 chart per week is monitored by each clinician in the peer review process. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of 16 patient records, 10 were reviewed for treatment plan content. The treatment plans contained global and non-specific goals; the contents did not address patient specific needs and goals as identified in the patients' personal histories and psychosocial evaluations in records; patient records # 4 and 13 did not contain treatment plan objectives that were specifically addressed as problems in record documentation.Additionally, the facility failed to provide documentation of timely treatment plan review with their patients. Patient # 12 had a treatment plan developed by her counselor on 11/15/07; the patient did not sign this document until 1/16/08. There was no documentation to state that patient worked on the treatment plan goals and objectives prior to the date of signature.
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Plan of Correction
The Program Director and Clinical Supervisor from Inpatient services are scheduled to conduct a training on treatment planning on 7/29/08. This training will include: realistic and tailored treatment plans to match the client's treatment needs and strengths. Short and long term goals and actions needed to reach these goals and specific measurable treatment objectives, individual and group counseling, service type and intensity needed not required.
Staff will be re-trained on the purpose of the treatment plan and the policy and procedures regarding timelines for client signatures and treatment plan updates.
Staff will be informed of the need to increase their documentation in progress notes of client's progress or lack of progress pertaining to areas identified on the client's treatment plans as identified during individual sessions.
The Program Director will monitor for compliance by reviewing 5 random charts per month and 1 chart per week is monitored by each clinician in the peer review process.
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715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of 16 patient records, 9 were reviewed for compliance with treatment plan updates. The facility failed to consistently document treatment plan updates in 3 patient records, #1, 3 and 12. Patient record # 1 was missing a treatment update for 5/08, patient record # 3 had no treatment plan update since 12/07 and patient record # 12 had no treatment plan updates since 1/08. Additionally, patient records #11 and 13 contained treatment plan updates from 4/08 and 6/08 contained the same information (identical).
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Plan of Correction
New treatment plan forms have been developed to include the treatment plan and the treatment plan update on the same form. These forms will be implemented beginning 7/30/08. Every 60 days all treatment goals and objectives will be reviewed and updated and a new treatment plan must be initiated whether goals are to be continued or completed. A training conducted by the Program Director and Clinical Supervisor from Inpatient services on the new form, treatment planning and treatment plan updates is scheduled for 7/29/08.
Director is individually addressing any staff member not completing the treatment plan updates to satisfactory standards or within the 60 day time period.
A pre and post exam on the 709 and 715 regulations has been designed and will be presented to the staff on 8/6/08.
The Program Director will monitor for compliance by reviewing 5 random charts per month and 1 chart per week is monitored by each clinician in the peer review process.
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